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Paul University Dumaguete

Nursing Department

Dumaguete City

A Case Presentation


Prepared by:

April Rose Ranas

Mary Ann Pabillo

Paul Vincent M. Saldariega

Presented to:

Mrs. Ma. Antonia D. Lumente, RN

Clinical Instructor
Biographical Data

Name: Alma T. Rabac

Age: 37 yrs. Old
Sex: Female
Address: Nabago, Silab, Amlan
Birth Date: April 7, 1972
Birth Place: Nabago, Silab, Amlan
Nationality: Filipino
Marital Status: Single
Religion: Roman Catholic
Occupation: Self-employed
Health Insurance: None
Source and Reliability: Patient: 20%
S/O: 80%

Reason for Seeking Health Care

“Nag nana man gud ang iyang tahi.” as verbalized by the significant others.

Past Health History

Childhood illness: fever
Hospitalization: Childbirth (Dec. 20, 2009)
Surgeries: Caesarean Section (Dec. 2, 2009)
Chronic Illness: None
Immunization: BCG, DPT, Hep. B
Allergies: None
Medication: None
Recent Travel: None

Present Health History

Patient had delivery with Caesarean Section at the Provincial Hospital
on December 20, 2009. The patient didn’t take the antibiotics given to her by
her doctor to prevent infection. On December 24 at the hospital, when the
patient was urinating in the CR, her stitches from the Caesarean Section were
opened and the organs came out of her abdomen specifically the intestines.
She was then cured by the hospital but then the patient was still not healing
because the hospital doesn’t have the capacity to cure her and so they
decided the patient then to be discharged. Patient was discharged at
Provincial Hospital on January 1 and brought home. On January 2, she was
brought to Holy Child Hospital by her family because her stitched wound was
secreting pus.

Psychosocial Profile
Health Practices and Beliefs: Patient doesn’t believe in Medical doctors but
believes in quack doctors.
Nutritional Pattern: Soft diet
Activity and exercise Pattern: Patient usually spends her time in doing
household chores.
Recreation, pet, hobbies: None
Sleep Pattern: Usually sleeps at 1o pm and sleeps at least 8 hours.
Personal Habits: No vices in particular.
Family History:

Father: 60 yrs. old, alive and well

Mother: 58 yrs. old, alive and well
Siblings: (Patient): 37 yrs. old
Sister: 35 yrs. old, alive and well
Sister: 32 yrs. old, alive and well
Sister: 27 yrs. old, alive and well Brother: 18 yrs. old, alive
and well
Brother: 21 yrs. old, alive and well Brother: 12 yrs. old, alive
and well

Family Genogram:

- Male

- Female

- Patient

Psychosocial History:

Patient has a good and strong relationship with her family. She loves
her family thus in times of some problems she was there to help them. She is
also close to their relatives and always communicates to them. Aside from
her family, she is also a good friend. She is a good daughter and a good role
model to her younger siblings.

Environmental History:

She is a resident Nabago, Silab, Amlan, Negros Oriental. Their house is

conducive for all of them according to the father. There, she can breath fresh
air and eat some fresh fruits and vegetables from their backyard and

Spiritual History:
The patient and her family is a Roman Catholic. They participated in
some religious activities of the church. They also attended mass every

Physical Assessment

Integumentary System
• Uniform in skin color with slightly darker exposed area
• Presence of generalized black area at the neck
• Presence of scar at shin of left leg
• Presence of dead nail on thumb of right foot
• Presence of nevus at left upper arm
• Presence of wound at the abdomen with length of 16 cm and
width of 18 cm
• No unusual skin odor
• Skin is cold to touch
• Good skin turgor
• Hairs evenly distributed
• Scalp intact with no lesions

• Upper eyelids covers on half of the upper iris
• Eyelids in contact with eyeballs with no lesions
• Lacrimal glands no swelling, redness and drainage
• Positive corneal reflex
• Sclera white in color
• Lens clear, smooth and glistening
• Brown iris color
• Pupil equally round, reactive to light and accommodation

• Normal in shape, no lesions, skin intact, color consistent with skin color
• Soft and pliable, non-tender
• No presence of drainage and secretions

• Midline placement, shape is symmetrical and consistent with age
• No nasal flaring, no drainage
• Non-tender, sinuses are non-tender
• Mucosa pink and moist
• Naris patent

• Oral mucosa pink, moist, intact, no lesions
• Tongue pink, moist, papillae intact
• Lips midline, symmetrical, cracked and dry
• Uvula in midline placement, moist, with no lesions

• Black color around the neck
• Symmetrical, no lesions, no secretions
• No masses, non-tender

Lymph Nodes
• Non-palpable and non-tender

Breast and Axillae

• Skin color uniform, lighter than exposed areas
• Non-tender and no bulges
• No lesions, and no masses
• No discharges, no unusual odor

• Bloated abdomen with circumference of 88 cm.
• Presence of infected stitched wound
• Skin color lighter than exposed areas
• Tenderness noted when palpated at all four quadrants.

• Muscle soft, slightly weak, non-tender
• No abnormal movement

Anatomy and Physiology

Abdominal Cavity

The cavity within the abdomen, the space between the abdominal wall and
the spine. The abdominal cavity is hardly an empty space. It contains a number of
crucial organs including the lower part of the esophagus, the stomach, small
intestine, colon, rectum, liver, gallbladder, pancreas, spleen, kidneys, and bladder.

Peritoneal Cavity – subset of the abdominal cavity lined by continuous serous

membrane called peritoneum.
Sepsis is a serious infection usually caused by bacteria — which can originate
in many body parts, such as the lungs, intestines, urinary tract, or skin — that make
toxins that cause the immune system to attack the body's own organs and tissues.

Sepsis can be frightening because it can lead to serious complications that affect
the kidneys, lungs, brain, and hearing, and can even cause death. Sepsis can affect
people of any age, but is more common in:

• infants under 3 months, whose immune systems haven't developed

enough to fight off overwhelming infections
• the elderly
• people with chronic medical conditions
• those whose immune systems are compromised from conditions such as

Final Diagnosis: